The Role of Laparoscopy in the Treatment of Anastomotic Leaks After Minimally Invasive Colorectal Resections for Cancer.

AIM OF THE STUDY: The aim of this study was to describe the role of laparoscopy in the treatment of leaks occurring after minimally invasive colorectal resections. MATERIALS AND METHODS: Thirty-four of 566 consecutive patients who underwent minimally invasive colorectal resection for cancer between January 2004 and December 2012 and who showed signs of anastomotic leakage (6%) requiring reoperation were studied using a prospectively maintained database. Patient characteristics, clinical signs, the surgical approach, the role of laparoscopy, operative and postoperative results, and the rate of permanent stoma were analyzed. RESULTS: The median time to diagnosis of an anastomotic leak after surgery was 5.5 days. The median time to reoperation from the diagnosis of leakage was 2 days. Leaks were treated laparoscopically in 21 of 34 (61.8%) patients. Anastomoses were dismantled in 14 patients (41.2%) and the procedure was performed laparoscopically in 28.6% of the cases. The postoperative morbidity was 55.9%, the perioperative mortality 5.7%, and the rate of permanent stoma was 8.8%. CONCLUSIONS: Laparoscopic reoperation can be performed in most cases of anastomotic leaks occurring after minimally invasive colorectal resection for cancer. Anastomosis can be dismantled laparoscopically in 28.6% of the cases. A permanent stoma was necessary only in patients with terminal stomas.

[Local excision of giant rectal polypoid neoplasms]. / Escissione locale delle neoplasie polipoidi giganti del retto.

Local excision is the best therapeutic option for giant adenomas of the rectum. Parks technique for lower rectal lesions and the T.E.M. technique for lesions localised in the middle and upper rectum offer exceptionally good exposure, allowing radical excision in the case of early low-risk T1 adenocarcinomas (well or moderately differentiated [G1/2] without lymphovascular invasion [L0]). From July 1987 to March 2006, 224 patients were treated by local excision for rectal lesions in our department. In 48 patients (21.4%) a large sessile benign lesion was diagnosed preoperatively. In 3 patients with a preoperative diagnosis of severe dysplasia (Tis) final pathology showed adenoma and for this reason they were included in our study group. A total of 51 patients with giant preoperative benign lesions were treated by local excision (Parks technique, T.E.M. or both). Twenty-five (49%) patients had a definitive diagnosis of adenocarcinoma: in situ (pTis) in 22 patients (88%), pT1 in 2 patients (8%) and pT2 in 1 patient (4%). In 26 patients (51%) the diagnosis was adenoma. The overall local recurrence rate was 9.8% (5/51); the recurrence rate was 7.6% (2/26) for adenomas and 12% (3/25) for carcinomas. The median hospital stay was 7 days (range 3-39). There was no operative mortality. Giant sessile polypoid lesions localized in the middle and upper rectum are best treated with T.E.M., while Parks technique is a good option in lower rectal tumours. These techniques, if correctly indicated and well performed, offer great advantages in terms of safety and radicality. In our experience the operative mortality was nil and the morbidity and recurrence rates were low.

[Endoscopic-laparoscopic treatment of neoplastic occlusion of the left colon]. / Il trattamento endoscopico laparoscopico dell'occluslone neoplastica del colon sinistro.

About a third of patients with colorectal carcinoma have acute colonic obstruction requiring emergency surgery. The surgical options are: intraoperative lavage and resection of the colonic segment involved with primary anastomosis; subtotal colectomy with primary anastomosis; colostomy followed by resection; and resection of the colonic segment involved with an end colostomy (Hartman's procedure) requiring a second operation to reconstruct the colon. These procedures present risks and are associated with a poor quality of life. Endoscopic colonic stent insertion effectively decompresses the obstructed colon allowing bowel preparation and elective resection. In this article we present 2 cases successfully treated with the use of stents followed by a laparoscopic resection. We also describe technical details concerning the endoscopy and laparoscopy procedure, discuss the advantages of this treatment and present a review of the literature. One patient underwent a left hemicolectomy; while the other was treated with splenic flexure resection. No complications occurred after surgery. Histological staging revealed a pT3 pNO pMx G2 and a pT4 pN1 pM1 G2 adenocarcinoma, respectively. This initial experience shows that endoscopic colonic stent insertion can effectively resolve the neoplastic obstruction, allowing safe elective surgery. The use of stents does not prevent a laparoscopic approach.

Hürthle cell tumors of the thyroid gland. Personal experience and review of literature.

BACKGROUND: Oncocytic cell neoplasm of the thyroid is currently recognized as a histological entity, but doubts still exist about its clinical and evolutionary categorization. Controversies concern occurrence and frequency of malignant forms, natural history and therapeutic strategies. MATERIALS AND METHODS: The authors report six cases of Hürthle cell tumor. Five cases were adenoma, one was carcinoma. Morpho-functional pre-operative evaluation and inter-operative histopathological test were performed in all patients. One patient underwent lobectomy (absence of unusual characteristics of the adenoma Hürthle cell) and five underwent total thyroidectomies (1 carcinoma). All patients were treated with suppressive hormonal therapy. RESULTS: No mortality and morbidity was recorded. All patients are undergoing follow-up (adenomas: average 64.2 months; carcinoma: 132 months) and none of them show recurrent symptoms. DISCUSSION: Hürthle cell tumors can be diversified in adenoma and carcinoma. Almost all reports classify oncocytic nodules as malignant when capsular and/or vascular invasion is present or when there is peri-thyroid tissue infiltration or lymphatic or hematic metastases. A clear differentiation between adenoma and carcinoma is determined by a histological test. Also an intra-operative histopathological analysis is sometimes unable to show minimal signs of invasion. Conflicting observations about the biological behaviour of Hürthle cell neoplasm lead to different therapeutic strategies. The authors believe lobectomy is the treatment of choice when a clear histological diagnosis of adenoma has been made. When carcinoma is diagnosed or when doubts exist after intraoperative histological test, the authors recommend total thyroidectomy followed by scintigraphic test and preventive radio-active therapy. All patients should be treated with suppressive hormonal therapy and undergo periodic check-ups.